The present invention relates generally to intracranial pressure (ICP) monitoring. Specifically, the invention relates to a method and apparatus of non-invasively, without requiring a breach of the skin, skull, or dura, monitoring ICP. More specifically, the invention provides a method and apparatus for stimulating and interpreting predictable external effects of elevated ICP such as changes in cochlear impedance coupling to monitor ICP. In one embodiment, the system non-invasively and continuously monitors ICP by stimulating and interpreting predictable changes measured in the otoacoustic emission (OAE) signal of the patient.
Intracranial pressure is closely related to cerebral perfusion (blood flow in the brain). Elevated ICP reduces cerebral perfusion pressure (CPP), and if uncontrolled, results in vomiting, headaches, blurred vision, or loss of consciousness, escalating to permanent brain damage, and eventually a fatal hemorrhage at the base of the skull. Increased ICP is a medical/surgical emergency. Particular instances where it is desirable to monitor ICP are in traumatic brain injury (TBI) victims, stroke victims, hydrocephalus patients, and patients undergoing intracranial procedures, xe2x80x9cshaken babyxe2x80x9d syndrome, kidney dialysis, or artificial liver support. Current methods of monitoring ICP are typically invasive, expensive, and/or difficult to perform outside of a hospital setting.
Traumatic Brain Injury
An estimated 1.75 million TBI""s occur annually (extrapolated from 1,540,000 TBI""s in 1991) in the United States. The U.S. Department of Education, National Institute on Disability and Rehabilitation Research in conjunction with 17 TBI research hospitals around the U.S. have established a set of indicators for classification of TBI:
1) Documented loss of consciousness for an unspecified time;
2) Amnesia for the event. No recall of the actual trauma;
3) A Glasgow Coma Scale (GCS) score of less than 15 during the first 24 hours.
Of these indicators, amnesia assessment is a preferred indicator of TBI severity. Amnesia of one day is considered moderate, while one month of amnesia indicates severe TBI. Although amnesia is a good indicator of TBI severity and a reasonable predictor of long term outcomes, this slow evaluation method provides no help in emergency response to patient diagnosis or treatment.
The GCS is a TBI severity assessment system using subjective observations in three basic categories: eye opening (E), best motor response (M), and verbal response (V). A patient""s GCS score is the sum of the patients E, B, and V scores. This sum ranges from 3 to 15 with 3 indicating severe TBS and 15 indicating no or very mild TBS. The non-invasive nature of CT scans make them a very common procedure for TBI patients whose GCS score is mild or moderate, but the data is slow and expensive. The patient must be brought to the equipment and, in many cases, the patient cannot be immediately moved. The cost is compounded because CTs do not provide direct assessment of ICP (two or more scans are required to assess trends) and in 9-13% of patients, the CT will be normal even with elevated ICP. Due to the invasiveness of current ICP monitoring procedures, the general practice is to not start invasive ICP monitoring unless the patient""s GCS score is less than or equal to 8, at which time the drawbacks of the procedure are outweighed by the severity of patient condition. This means 90% of hospitalized TBI patients are assessed only with GCS and possibly a CT scan. Significant rehabilitation problems have resulted in patients with mild or moderate GCS scores, highlighting the need for non-invasive ICP monitoring techniques. GCS assessment and CT scans are helpful, but clearly point out the time-sensitive need for more direct data.
Stroke
First time strokes can unpredictably lead to brain swelling. Strokes are divided into two main categories, (1) hemorrhagic (the bursting of a cerebral blood vessel), and (2) the more common ischemic (the blockage of a cerebral blood vessel). Correct diagnosis of the stroke type is critical because the clot-dissolving drug t-PA (and analogs), used to treat ischemic strokes, is contraindicated for hemorrhagic strokes. Furthermore, the diagnosis of stroke type is time critical because starting t-PA treatment more than 3 hours after stroke could result in a higher rate of bleeding into the brain. Approximately 80% of all strokes each year are ischemic. ICP in this type of stroke initially remains low, but elevates as the loss of blood traumatizes the brain. ICP will also elevate when the clot is removed and blood flow is restored. Hemorrhagic strokes involve the direct complication of elevated ICP.
Hydrocephalus
Ventroperneal shunts are implanted to treat hydrocephalus. A CT scan cannot be used for patients with hydrocephalus because the ventricles of the brain commonly remain swollen even with normal ICP, and the risk of invasive systems cannot be justified. Diagnosis of shunt system problems are currently based on symptoms reported by the patient or caregiver and are thus subjective. OAE is stable over a period of months and an ICP baseline could be stored for these patients and compared with measurements during future visits. Current ICP measurement technology does not provide adequate means for treating patients with hydrocephalus because of the possible inaccurate readings and the risk inherent in invasive measurement procedures.
Intracranial Procedures
There is a current medical need for ICP monitoring for patient recovering from elective intracranial surgery. A retrospective study found elevated ICP postoperatively in 17% of patients who underwent supratentorial or infratentorial surgery. Of these, over one fourth experienced clinical symptoms latent or concurrent to ICP elevation. Medical personnel need to be able to identify these patients and administer therapy before any clinical symptoms are detected. It is interesting to note that during the study, which used invasive methods to measure ICP, the infection rate was 1.2%, highlighting the risk of invasive ICP monitoring.
Laparoscopic and Abdominal Insulflation
Laparoscopic procedures are often performed requiring abdominal insulflation concomitant with Trendelenburg (head down tilt) position. The combination of anesthetic, body position, and insulflation can substantially elevate ICP. Due to the prohibitive additional cost and risk, routine ICP monitoring during these procedures is not done. However, there is growing concern about elevated ICP during these procedures.
Liver and Kidney Support
There is a current medical need to assess ICP variation in patients who are in the latter stages of liver failure and require external liver support (i.e. artificial liver). As the liver fails, toxins build up in the body and this build up generally causes elevation of ICP. One measure of liver function (or therapy function) is to monitor ICP. As toxins build, ICP increases, thus allowing the physician (and possibly the patient) to anticipate when the next therapy session should commence. While on the artificial liver machine, toxins are removed, and ICP should fall, providing an indication of therapy function. A similar situation exists for patients being treated for kidney failure, either by hemodialysis or peritoneal dialysis.
Others
Additional causes for an increase in ICP include the following: meningitis, encephalitis, intracranial abscess, hemorrhage, shunt blockage, tumors, Reye""s Syndrome, xe2x80x9cshaken babyxe2x80x9d syndrome, and benign intracranial hypertension.
Normal intracranial pressure (ICP) for adults is between 5 mm/Hg and 15 mm/Hg. When ICP level is considered abnormal is controversial, however, it becomes a concern as it rises higher than 20 mm/Hg.
ICP is closely related to cerebral perfusion (blood flow in the brain). To a first approximation, the cerebral perfusion pressure (CPP) is the difference between an individual""s arterial blood pressure (ABP) and intracranial pressure (ICP). Thus, approximately, CPP=ABPxe2x88x92ICP. If one assumes ABP to be constant, then an increase in ICP results in less blood flow to the brain. Because of this relationship, and the difficulty of measuring CPP directly, ABP and ICP are often measured to assess CPP. In a healthy individual, automatic regulation mechanisms in the body keep ABP, ICP, and thus CPP within a normal range. These automatic regulation systems are often non-functional in brain trauma, stroke, hydrocephalic patients, and patients with liver or kidney failure, so that monitoring and management of ICP becomes a critical aspect of medical care. In addition, during surgeries such as abdominal laparoscopy, cardiac bypass, and following any type of cranial surgery, continuous, non-invasive monitoring of ICP, if it were economically and technically feasible, would be beneficial. Elevated ICP reduces CPP, and if uncontrolled, results in vomiting, headaches, blurred vision, or loss of consciousness, escalating to permanent brain damage, and eventually a fatal hemorrhage at the base of the skull.
Current ICP monitoring techniques are generally grouped as either invasive and non-invasive. The invasive group is further divided into soft tissue, for example lumbar puncture, and bone drilling procedures, for example subarachnoid screws or plugs, subdural catheters, and ventriculostomy catheters.
Lumbar Puncture
In a lumbar puncture or spinal tap, a clinician delicately passes a fine needle through the lower region of the back into the fluid of the spinal cord. Once the spinal spaces have been penetrated, ICP can be estimated by attaching a pressure sensor. The communication between the fluid in the spinal column and the cranium allows the physician to ascertain the pressure in the cranium. Though invasive, a lumbar puncture is sometimes preferred because it is a soft tissue procedure rather than a cranial procedure. Generally, a non-neuro clinician will not feel comfortable performing a cranial procedure, but will perform a lumbar puncture. This procedure does allow transient manipulation or sampling of the intracranial fluid system, but is often painful and many times results in after affects, and always raises patient apprehension. It is a short term procedure and is generally not considered for long term ICP monitoring.
Cranial ICP Assessment Methods
There are five common current invasive methods of measuring ICP which breach the skull: ventriculostomy, intraparenchymal fiberoptic catheter, epidural transducer, subdural catheter, and subdural bolt. These have varying degrees of invasiveness. A subarachnoid screw involves inserting the screw in a hole which has been drilled through the skull bone, but does not breach the dura. Such systems can be threaded like a screw, or just a xe2x80x9cfriction fitxe2x80x9d plug. A subdural catheter involves inserting the catheter a hole in the skull and dura, and squeezing the catheter between the dura and the brain itself. Ventriculostomy catheters are inserted through a hole drilled in the skull and dura, and are blindly forced through the gray matter such that the tip of the catheter is positioned in one of the cranial ventricles.
Of these methods, only a ventriculostomy can also be used to deliver therapy, which is usually draining fluid from the ventricles. The epidural approach has the lowest complication rate, but all suffer gradual loss of accuracy. The failure mechanism is stiffening of the dura and/or localized hematomas at the monitoring site. This known degradation starts immediately after implant and will make the transducer unreliable anywhere from 1 to 3 weeks post implant.
This invasive group, although medically accepted and routinely used, suffers several drawbacks. The transducer has to be calibrated in some fashion before insertion. The placement of the system requires a highly trained individual; in almost all clinical settings, this procedure is limited to physicians, and in most cases further limited to a specialist such as a neurosurgeon. This generally limits these procedures to larger medical facilities. Furthermore, there is a relatively short term (32-72 hours) reliability and stability of the system, either because of leaks or plugging of the transducer, or inadvertently being disturbed, or even being pulled out. This concern generally limits these procedures to a more intense monitoring setting such as an ICU. There are also associated risks of transducer placement such as brain or spinal cord damage and infection. Even though these risks are low, these concerns generally limit the group of non-invasive ICP monitoring techniques to the hospital setting and prevents standard use of the techniques in clinic or nursing home settings.
In the non-invasive group, the accepted, commercially available method of monitoring ICP consists of taking a CT or other image of the head, interpreting the image and observing changes in various features. This method requires a high level of skill to read and assess the images and requires that the patient be brought to the imaging equipment. In many cases, a scan is delayed or put off simply because the patient is not stable enough to be moved. Even after the patient is stable, the various tubes and equipment connections to the patient have to be accounted for during the trip to the CT, and many times additional personnel are required, with a respective increase in cost. In addition, the scans themselves are single measurementsxe2x80x94xe2x80x9csnap-shotsxe2x80x9d in time, of which at least two are required to assess subtle-changes and variations. A xe2x80x98seriesxe2x80x99 of scans could approximate continuous monitoring, but is not economically practical.
Other non-invasive ICP monitoring techniques have been developed. A non-invasive ICP monitoring system is taught in U.S. Pat. No. 4,841,986 to Marchbanks. This system is based on fine volume measurements of the external auditory canal during elicitation of the human stapedial reflex. The concept is that at normal ICP, the stapedial reflex will pull on the stapes, resulting in distortion of the tympanic membrane (ear drum). This will define a volume for that ICP level. As ICP increases, the stapes will be pushed away from the cochlea, and the stapedial reflex will pull on the stapes differently, resulting in a different distortion of the tympanic membrane, which can be measured as a delta volume. This system requires a rather loud sound to be output in the patients ear. Severe ambient noise and sealing constraints are inherent in the technology which lead to a cumbersome and time consuming setup. The system has a non-linear response, acting much like a threshold function.
A compliance measuring system taught by Paulat in EP 0933061A1 measures changes in ICP. The system uses micro volume measurements in the auditory canal similar to the Marchbanks system. The system detects the fine volume changes as the time varying ICP waves are communicated to the cochlea via the cochlear aqueduct, through the ossicles to the tympanic membrane. This device is AC coupled so it cannot monitor ICP changes over time (i.e. mean ICP values). It has been proposed that frequencies greater than 10 Hz could not be communicated via the cochlear aqueduct. Stated another way, respiration and heart rate frequencies may not be transmitted through the cochlear aqueduct.
In Bridger in U.S. Pat. No. 5,919,144, a non-invasive system is disclosed based on real-time analysis of acoustic interaction with the brain and changes in tissue acoustic properties as ICP changes.
Other non-invasive techniques include:
electro-magnetic techniques taught by Ko in U.S. Pat. Nos. 4,690,149 and 4,819,648, by Alperin in U.S. Pat. No. 5,993,398, and Paulat in U.S. Pat. No. 6,146,336;
ultra sonic or vibratory techniques such as U.S. Pat. No. 3,872,858 to Hudson et al., U.S. Pat. No. 4,043,321 to Soldner et al., U.S. Pat. Nos. 4,971,061 and 4,984,567 to Kageyama et al., U.S. Pat. Nos. 5,074,310 and 5,117,835 to Mick, U.S. Pat. Nos. 5,388,583 and 5,951,477 to Ragauskas et al., U.S. Pat. No. 5,411,028 to Bonnefous, U.S. Pat. No. 5,617,873 to Yost et al., U.S. Pat. No. 5,840,018 to Michaeli, U.S. Pat. No. 6,086,533 to Madsen, and U.S. Pat. No. 6,117,089 to Sinha;
jugular vein occlusion taught by Allocca in U.S. Pat. No. 4,204,547;
ocular latency in U.S. Pat. No. 4,564,022 to Rosenfeld et al.
Another system stated to be xe2x80x9cnon-invasivexe2x80x9d is described in U.S. Pat. No. 4,141,348 to Hittman and companion U.S. Pat. No. 4,186,751 to Fleischmann. This nuclear powered pressure sensor was not grouped with the other non-invasive systems because it is designed to be implanted totally under the scalp of the patient.
Each of the currently used and medically accepted methods of ICP assessment are deficient in some way, and all require a high skill level to administer. Because of the deficits in current measurement methodologies, there is a need for a non-invasive, easily administered, long-term, continuous assessment of ICP.
To address the difficulties noted above, it is an object of this invention to provide a continuous intracranial pressure monitoring system that is non-invasive and easily administered. The ICP monitoring system of the current invention stimulates and interprets predictable external effects of elevated ICP. In a preferred embodiment, the system non-invasively and continuously monitors ICP by stimulating and interpreting predictable changes measured in the otoacoustic emission (OAE) signal (transient, or cubic distortion) of the patient. The system may alternately non-invasively and continuously monitor ICP by stimulating, measuring, and interpreting other responses which rely on the transmission of vibrations through the middle ear cochlear interface, such as tympanograms (TGRAMs), ocular-acoustic reflex, auditory brainstem response (ABR), or cochlear microphonics. It should be apparent to those skilled in the art that other suitable measurements could be used in monitoring the ICP level. The measurements could be used individually, in conjunction with one another, or in concert with current invasive ICP measuring systems. One, two, or more of the above mentioned measurements may be used in concert with one, two, or more of heart rate, respiration rate, pulse oximeter, blood pressure, or other conventional xe2x80x98vital signsxe2x80x99 measurements.
The portability and ease of the invention enables more frequent ICP assessment in the areas identified previously as well as expansion of ICP assessment into areas heretofore considered economically or technically unfeasible. These new areas include first responders such as EMT""s, medics, ambulances, and law enforcement officers; long term care situations such as nursing homes, assisted living, and home care; athletic trainers (during, for example, concussion assessment), and military battlefield application.
In a preferred embodiment, the invention provides a system which utilizes predictable changes in OAE signals to assess and record changes in ICP over timexe2x80x94a system which is compact enough to be strapped to the patients"" arm during ambulance or other transport. This system allows EMT""s or other first responders to start monitoring changes in ICP, requiring only simple interface(s) to the patient. Examples of these simple interfaces include, but are not limited to; a plug transducer or tube inserted into the patients ear; pulse oximeter type clip on the finger or ear lobe; a stretchy band about the thorax to detect respiration. After arriving at the hospital or trauma center, the ICP history can be downloaded. Starting ICP monitoring early advantageously provides ER physicians expanded and prior time history of the patients changes in ICP to assist in diagnosis and treatments decisions. Many times a patient arrives at a health care facility with no apparent symptoms and is sent home, only to succumb to symptoms of elevated ICP later, resulting in another emergency transport to the hospital.
Another scenario where the invention is especially useful is for a non-symptomatic patient with a known head trauma arriving at a small regional health care facility with no neuro related specialists on staff. Currently, the ER physician is confronted with the decision to; send the patient to a larger facility via ground transport, wait and monitor the patient and if their condition deteriorates, or send the patient to a larger facility via air ambulance. With the present invention, the ER physician is provided with time history of the changes in ICP before sending the patient to a larger facility or home. The device can also be sent home with the non-symptomatic patient to continue ICP monitoring. By home monitoring following a possible brain trauma, a second emergency trip back to the hospital can be avoided.
In another embodiment, the invention is used in conjunction with an invasive pressure transducer such as a subarachnoid screw, or lumbar puncture, and the stored ICP data is characterized and quantified based on this reference. This is also used as a reference for future stored data. The pressure transducer interface may be incorporated within the invention apparatus, or a connection from the invention to a current pressure measuring system could be made using a wired or wireless (IR, RF, etc.) means. Also contemplated is the direct entry of the xe2x80x98referencexe2x80x99 pressure via keypad or other entry system.
In another embodiment, the invention is used as a continuous bedside monitorxe2x80x94a system which is portable in terms of size, weight, and power. This allows ICP monitoring to be started on a patient pre-operatively and follow the patient as the patient is moved to the operating room, recovery room, and hospital room. This advantageously allows physicians to monitor ICP during and following cranial, laparoscopic, or other procedures.
In another embodiment, a xe2x80x98templatexe2x80x99 of the patients normal ICP signal is captured and stored in the invention, and sent home with the patient, home care provider (parents or other guardians) or long term care provider (i.e. nursing homes). This allows the monitoring of the patients"" ICP to be continued following hospital or clinic discharge. This advantageously reduces the cost of long term ICP monitoring by moving the patient from the hospital setting to the nursing home setting, and makes periodic or even continuous ICP monitoring by home care givers economically feasible.
Hydrocephalic infants, brain trauma, or stroke survivors who cannot communicate internal symptoms can be monitored at a greatly reduced cost, yet without increasing risk to the patient. This is also advantageous in the clinical follow up of shunted patients since their ventricles remain swollen even under xe2x80x98normalxe2x80x99 ICP, rendering CT assessment of ICP worthless. Physicians would like to know the ICP of the patient, but are unwilling to subject the patient to an invasive procedure.
An aspect of the invention, which may be included in any of the embodiments, involves other signals (such as pulse rate, blood pressure, oxygen saturation, respiration rate, etc.) measured either as part of the apparatus of the invention, or measured and communicated by other equipment. The additional signals are analyzed in concert with the ICP data to further characterize and qualify the data.
Another aspect of the invention, which may be included in any of the embodiments, is to combine ICP and pulse oximeter (or other suitable measurement) inputs to provide an estimate of cerebral oxygenation.
Another aspect of the invention, which may be included in any of the embodiments, is to combine ICP and blood pressure (or other suitable measurement) inputs to provide the physician with an estimate of cerebral perfusion pressure (CPP).
Another aspect of the invention, which may be included in any of the embodiments, is an accelerometer or other suitable position sensor which is incorporated within the invention to compensate or otherwise offset the postural influences in ICP measurements.
Another aspect of the invention, which may be included in any of the embodiments, is to measure ICP using both ears and provide hemispheric information to the physician.
Another aspect of the invention, which may be included in any of the embodiments, includes a noise canceling system to enhance the signal to noise ratio (SNR) of the ICP signal.
Another aspect of the invention, which may be included in any of the embodiments, synchronizes the ICP measurement to the same phase of the cardiac rhythm or respiration rhythm, or both, to improve the SNR of the ICP signal.
Another aspect of the invention, which may be included in any of the embodiments, synchronizes the ICP measurement to the same phase of the cardiac rhythm or respiration rhythm, or both, to assess the patency of the cochlear aqueduct.
Another aspect of the invention, which may be included in any of the embodiments, is to measure the ICP synchronized to at least two known phases of the cardiac rhythm or respiration rhythm, or both, preferably at diastole and systole/inhalation and expiration, and use that delta to further quantify the ICP reading.
Another aspect of the invention, which may be included in any of the embodiments, is to measure the ICP synchronized to cardiac diastole and systole and/or respiration inhalation and expiration in at least two distinct ICP levels, the levels being manipulated by head tilt, or forced by some chemical means, such as ingestion of glycol. This allows at least 4 different ICP readings, and can be used to further qualify and quantify the ICP reading.
Another aspect of the invention, which may be included in any of the embodiments, is to measure the ICP using OAEs around 2 khz to assess the presence of non-equalized middle ear pressure which can distort or mask the ICP signal in OAE""s.